MEDICARE: FAMILY LEGACY MENTAL HEALTH SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	101YP2500X	Professional Counselor	6102775	NC
3	103TC0700X	Clinical Psychologist	6107485	NC
4	103TC1900X	Counseling Psychologist	6001168	NC
5	106H00000X	Marriage & Family Therapist	6105171	NC
6	2080A0000X	Pediatric Adolescent Medicine Physician	9300596	NC
7	251B00000X	Case Management Agency
8	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932371655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY LEGACY MENTAL HEALTH SERVICES INC

Provider Business Mailing Address
First Line	:	1011 SCHAUB DR
Second Line	:	SUITE 200
City	:	RALEIGH
State	:	NC
Zip	:	27606-1862
Country	:	US
Telephone Number	:	919-834-2000
Fax Number	:	919-834-2001

Provider Business Practice Location Address
First Line	:	1007 BROAD ST
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27705-4143
Country	:	US
Telephone Number	:	919-834-2000
Fax Number	:	919-834-2001

Authorized Official
Title or Position	:	CEO
Name	:	LISA DYAN STACEY
Credential	:	B.S. Q.P
Telephone Number	:	919-834-2000

Provider Enumeration Date	:	04/02/2008
Last Update Date	:	06/18/2014

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